Provider Demographics
NPI:1417919218
Name:BAHNER, RODERICK JR (MD)
Entity Type:Individual
Prefix:
First Name:RODERICK
Middle Name:
Last Name:BAHNER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1532 COPPERSTONE DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-2220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5655 FRIST BLVD
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:TN
Practice Address - Zip Code:37076-2053
Practice Address - Country:US
Practice Address - Phone:615-316-3541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD037171207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
H19702Medicare UPIN
TN3886117Medicare PIN